Immunosuppression and renal outcome in congenital and pediatric steroid-resistant nephrotic syndrome

BACKGROUND AND OBJECTIVES

Mutations in podocyte genes are associated with steroid-resistant nephrotic syndrome (SRNS), mostly affecting younger age groups. To date, it is unclear whether these patients benefit from intensified immunosuppression with cyclosporine A (CsA). The aim of this study was to evaluate the influence of podocyte gene defects in congenital nephrotic syndrome (CNS) and pediatric SRNS on the efficacy of CsA therapy and preservation of renal function.

DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS

Genotyping was performed in 91 CNS/SRNS patients, irrespective of age at manifestation or response to CsA.

RESULTS

Mutations were identified in 52% of families (11 NPHS1, 17 NPHS2, 11 WT1, 1 LAMB2, 3 TRPC6). Sixty-eight percent of patients with nongenetic SRNS responded to CsA, most of them achieved complete remission. In contrast, none of the patients with genetic CNS/SRNS experienced a complete remission and only two (17%) achieved a partial response, both affected by a WT1 mutation. Preservation of renal function was significantly better in children with nongenetic disease after a mean follow-up time of 8.6 years (ESRD in 29% versus 71%).

CONCLUSIONS

The mutation detection rate in our population was high (52%). Most patients with genetic CNS/SRNS did not benefit from CsA with significantly lower response rates compared with nongenetic patients and showed rapid progression to end-stage renal failure. These data strongly support the idea not to expose CNS/SRNS patients with inherited defects related to podocyte function to intensified immunosuppression with CsA.

[Concept to improve adherence in adolescents following renal transplantation: vision or reality?]

Transition to adult care is a generic issue for subspecialties dealing with chronic illness and has received little attention to date. The transition from pediatric to adult care for renal transplant recipients is recognized as a high-risk period for poor graft outcome associated with more than 20% graft loss. Non-adherence to immunosuppressive medications is one of the most important factors contributing to graft loss during this period. Transition is, therefore, a concern of both pediatric and adult providers, and medical improvements in this area will require more effective collaboration at this interface. This report explores medical and psychological risk factors and barriers during the transition process. In addition, a specially developed coaching concept for young adults is presented intended to assist adolescents with early childhood end-stage renal disease in the transition from pediatric to adult care.

Perceived parental rearing in subjects with obsessive-compulsive disorder and their siblings

OBJECTIVE

Perceived parenting in patients suffering from obsessive-compulsive disorder (OCD) is examined. We attempted to overcome some methodological limitations of prior studies by taking age of onset, parental OCD and comorbid depression into consideration. In addition, we included data from unaffected siblings to corroborate information on parental rearing.

METHOD

One hundred and twenty-two cases with OCD and 41 of their siblings as well as 59 healthy controls and 45 of their siblings completed the German short-version of the EMBU (FEE).

RESULTS

Obsessive-compulsive disorder cases reported less parental warmth and more parental rejection and control. Further analyses indicated that parenting is also associated with OCD in cases with late onset and cases without parents affected by OCD. OCD cases with comorbid depression described their parents particularly negatively. Data from siblings indicated good validity of perceived parenting in OCD.

CONCLUSION

This study provides further evidence for dysfunctional child rearing being relevant to the development of OCD and depression.

Angiotensin receptor blocker reduces proteinuria independently of blood pressure in children already treated with Angiotensin-converting enzyme inhibitors

BACKGROUND/AIMS

Dual blockade of the renin-angiotensin system with angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) has higher antiproteinuric effects than single blockade in adults. In children, little is known on dual blockade of the renin-angiotensin system. The study investigates whether adding an ARB to proteinuric children already on ACEI reduces proteinuria.

METHODS

A total of 10 children (median age 13.3 years) with chronic kidney disease and persistent proteinuria despite maximal dose of ACEI were included. Losartan was given at an initial dose 0.8 mg/kg/day. Proteinuria, blood pressure (BP) and renal function (glomerular filtration rate) were measured.

RESULTS

Mean proteinuria decreased from 484 +/- 290 mg/mmol creatinine to 223 +/- 197 after 1-3 months of losartan treatment and remained stable at 234 +/- 153, 224 +/- 177 and 195 +/- 133 after 3-6, 6-12 months and at the last follow-up check (median 1.9 years, p < 0.05 for all visits vs. before treatment). The median percentage decrease in proteinuria was 66, 56, 44 and 66% during the study periods. No significant change in BP, glomerular filtration rate or serum potassium was observed. One child complained of rash, which led to discontinuation of losartan.

CONCLUSION

Adding an ARB to current ACEI treatment can further reduce proteinuria in children with chronic kidney disease without affecting BP.

[The readiness of staff in general medical practices to participate in a smoking cessation programme]

AIM

So far, the chances for tobacco prevention are not currently implemented sufficiently in general practices. The involvement of practice nurses (PN) could contribute to reach more patients. This study investigated the characteristics of PN which could be relevant for the implementation of counselling offers.

METHODS

A total of 216 general practices was randomly selected from all general practitioners registered for primary care in a defined region in West Pomerania. The participation rate was 69% (n=151). A total of 209 PN participated in a training and 94.3% filled in the questionnaire.

RESULTS

The data indicated a smoking prevalence rate of 30.3% among PN. Their motivation, to offer counselling measures in general practices was higher on average than the confidence to realise such interventions. There was no association between characteristics of PN such as age, number of work years in the practice, hours worked per week or smoking status and motivation or confidence measures.

CONCLUSION

There is a need for proactive interventions to decrease the smoking prevalence among PN. Furthermore, it should be examined which skills and knowledge are essential for PN nurses to manage new tasks with a high level of confidence.

Improved growth and cardiovascular risk after late steroid withdrawal: 2-year results of a prospective, randomised trial in paediatric renal transplantation

BACKGROUND

Long-term corticosteroid treatment impairs growth and increases cardiovascular risk factors. Hence, steroid withdrawal constitutes a major topic in paediatric renal transplantation and maintenance immunosuppression.

METHODS

The lack of data from randomised controlled trials caused us to conduct the first prospective, randomised, multicentre study on late steroid withdrawal among paediatric kidney allograft recipients treated with standard-dose cyclosporine microemulsion (CsA) and mycophenolate mofetil (MMF) for 2 years. Forty-two low- or regular-immunologic risk patients were randomly assigned, >or=1 year post-transplant, to continue taking or to withdraw steroids over 3 months.

RESULTS

Two years after steroid withdrawal, they showed a longitudinal growth superior to controls [mean height standard deviation score (SDS) gain, 0.6 +/- 0.1 SDS versus -0.2 +/- 0.1 SDS (P < 0.001)]. The prevalence of the metabolic syndrome declined significantly (P < 0.05), 2 years after steroid withdrawal, from 39% (9/23) to 6% (1/16). Steroid-free patients had less frequent arterial hypertension (50% versus 93% (P < 0.05)) and required fewer antihypertensive drugs [0.6 +/- 0.2 versus 1.5 +/- 0.3 (P < 0.05 versus control)]. Additionally, they had a significantly improved carbohydrate and lipid metabolism with fewer hypercholesterolaemia and hypertriglyceridaemia (P < 0.05 versus control). Patient and graft survival amounted to 100%. Allograft function remained stable 2 years after steroid withdrawal. The incidence of acute rejections was similar in the steroid-withdrawal group (1/23, 4%) and controls (2/19, 11%).

CONCLUSION

Late steroid withdrawal in selected CsA- and MMF-treated paediatric kidney transplant recipients improves growth, mitigates cardiovascular risk factors and reduces the prevalence of the metabolic syndrome, at no increased risk of acute rejection or unstable graft function.

Smoking prevalence in Type 2 diabetes: results of the Study of Health in Pomerania (SHIP) and the German National Health Interview and Examination Survey (GNHIES)

AIMS

Smoking contributes to the development of diabetes and diabetes-related complications. Currently, data on smoking prevalence in subjects with diabetes in Germany are lacking. The aim of our analysis was to determine smoking prevalence in adults with Type 2 diabetes mellitus using data from the two population-based studies in Germany.

METHODS

From the Study of Health in Pomerania (SHIP) (n = 4283) and the 1998 German National Health Interview and Examination Survey (GNHIES 98) (n = 6663) subjects aged 20-79 years were investigated. Descriptive statistics on smoking prevalence and behaviours were calculated for Type 2 diabetes mellitus and compared with the general population using weightings reflecting the European adult population.

RESULTS

Overall, the prevalence of current smokers was lower among persons with than without Type 2 diabetes mellitus in SHIP (17.3% vs. 38.0%) and in GNHIES 98 (24.7% vs. 32.1%). Only in men, there were more former smokers in Type 2 diabetic patients than in subjects without diabetes in both studies. Among current and former smokers, the number of cigarettes smoked was higher among persons with than without Type 2 diabetes mellitus. For men, this finding was consistent in SHIP and GNHIES 98, while in women, this difference was only observed in GNHIES 98.

CONCLUSIONS

The associations between smoking and Type 2 diabetes mellitus are likely to reflect behavioural changes secondary to illness or medical counselling. The high proportion of current smokers among Type 2 diabetic patients, particularly men, should be monitored in repeated surveys following the introduction of disease management programmes.

[Readiness to provide smoking cessation counselling--results of a survey among general practitioners in Brandenburg]

BACKGROUND

The effectiveness of brief interventions on smoking cessation together with regular visits to the general practitioners (GP) has been proven. Nevertheless, the guidelines for smoking cessation are not currently implemented sufficiently. A lack of financial resources, time, and consulting abilities prevent GPs from offering systematic advice on smoking cessation. This study examine 1) to what extent GPs ask their patients to provide information about their smoking habits and to what extent they document this, 2) how willing, and 3) how confident GPs are to offer all smoking patient counselling, and 4) which factors influence their level of confidence.

METHODS

From August 2005 until May 2006, a questionnaire was sent to all 1 247 GPs in Brandenburg. In all 68 practices was excluded for several reasons (closed practice, death, not providing primary care) a total of 54.0% (n=637) of the GPs took part.

RESULTS

30.0% of the GPs documented the smoking status of their patients during the first consultation. 12.9% had already offered advice to all their smoking patients, while 27.6% were not willing to offer advice to all smoking patients. The average confidence of GPs to offer all smoking patients advice on smoking cessation was 4.1 (SD=2.6) on scale of 1 to 10 (1=not at all confident and 10=very confident). The confidence of non-smoking GPs to offer an advice was higher in comparison with smoking GPs.

CONSEQUENCES

To motivate GPs to offer advice on smoking cessation, it seems necessary to change some conditions. This includes programms, initiated by professional medical associations, to help colleagues stop smoking. Further studies should indicate whether the inclusion of practice colleagues in screening and regular updates of the patient's smoking status increase the number of regular counselling.

Estimated one-yr glomerular filtration rate is an excellent predictor of long-term graft survival in pediatric first kidney transplants

Acute rejection episodes following pediatric renal transplantation have been progressively reduced by recent immunosuppressive regimens. Nevertheless, grafts continue to fail over time and surrogate parameters for long-term RGS are lacking. We investigated post-transplant renal function within the first yr as an independent predictor of long-term RGS in 104 pediatric first kidney transplant recipients (mean age 11.1 +/- 3.9 yr; mean follow-up 8.3 +/- 3.5 yr) transplanted between January 1989 and December 2000. GFR was assessed by use of the Schwartz formula at 30 days and six and 12 months after transplantation, respectively. Patients were further stratified at all times according to GFR: (i) GFR<45 mL/min/1.73 m(2), (ii) GFR 45-80 mL/min/1.73 m(2), and (iii) GFR>80 mL/min/1.73 m(2). Cox regression analysis including factors potentially influencing long-term RGS, e.g., age, gender, transplant yr, HLA-mismatch, underlying renal disease, clinical acute rejection, absolute GFR as well as the change in GFR within the first yr was performed. Graft failure occurred in 24 out of 104 patients (23%) 6.2 yr (mean) after transplantation corresponding to a cumulative five-yr graft survival of 87.5%. GFRs at 30 days and six and 12 months were significantly associated with long-term RGS in the univariate cox regression analysis (GFR at 30 days, p = 0.045; GFR at six months, p = 0.004; GFR at 12 months, p < 0.001). None of the other variables were significant parameters of correlation. Multivariate cox analysis revealed a GFR below 45 mL/min/1.73 m(2) at 12 months after transplantation as the only independent predictor of long-term RGS (hazard ratio 55.9, 95% CI 5.29-591, p = 0.001). GFR at 12 months post-transplant is an excellent surrogate parameter for long-term RGS in children. This parameter might be useful as a primary end-point in short-term pediatric clinical trials.

Intention to quit smoking: is the partner's smoking status associated with the smoker's intention to quit?

BACKGROUND

Smoking behavior among couples is often similar.

PURPOSE

The aim of the study was to examine the relationship between the partner's smoking status and the intention to stop smoking of the index person.

METHOD

Cross-sectional data of 1,044 patients in a random sample of 34 general medical practices in northeastern Germany were analyzed.

RESULTS

Among smokers with a non-smoking partner (SNP), more intended to quit smoking in the next six months (37.0% vs. 31.4%), compared to smokers with a smoking partner (SSP). Also, more SNP intended to quit in the next four weeks (4.7% vs. 2.7%) compared to SSP. SNP were more active in the use of self-change strategies than SSP.

CONCLUSION

The data confirm that the partner's smoking status is related to the intention to quit smoking. Interventions should address the different needs of both smokers with a smoking partner and those with a non-smoking partner.

Urinary tract infections in children after renal transplantation

Urinary tract infections (UTI) after pediatric kidney transplantation (KTX) are an important clinical problem and occur in 15-33% of patients. Febrile UTI, whether occurring in the transplanted kidney or the native kidney, should be differentiated from afebrile UTI. The latter may cause significant morbidity and is usually associated with acute graft dysfunction. Risk factors for (febrile) UTI include anatomical, functional, and demographic factors as well as baseline immunosuppression and foreign material, such as catheters and stents. Meticulous surveillance, diagnosis, and treatment of UTI is important to minimize acute morbidity and compromise of long-term graft function. In febrile UTI, parenteral antibiotics are usually indicated, although controlled data are not available. As most data concerning UTI have been accumulated retrospectively, future prospective studies have to be performed to clarify pathogenetic mechanisms and risk factors, improve prophylaxis and treatment, and ultimately optimize long-term renal graft survival.

[Diversity and accessibility of smoking cessation aids in the internet]

AIM OF THE STUDY

Only a few smokers use smoking cessation aids. The Internet can act as a medium to improve the dissemination of traditional smoking cessation aids, but can also provide direct help by its own interactive capabilities. The purpose of this study is to give an overview of the different smoking cessation aids offered via the Internet and to categorise their contents.

METHODS

Two different search strategies were used to find smoking cessation aids on the Internet. The first was a search with the search engine Google. Six search terms were previously generated by interviews with one hundred smokers. Using these terms, the Google search resulted in a list of 106 websites. The second strategy was a direct search on 31 websites of different health-related institutions. To classify the smoking cessation aids on the websites, a system of different categories was developed.

RESULTS

The offers for smoking cessation on the Internet could be assigned to 11 categories. General information about smoking cessation was the most and interactive programs was the least represented category. The websites of the health-related institutions offered a larger variety of directly useable smoking cessation aids (39%) than the websites retrieved via Google (29%).

CONCLUSION

Interactive smoking cessation aids which provide individual support are still underrepresented on the Internet. Direct search strategies on the pages of health-related institutions were more promising than the use of a search engine. The proactive promotion of quality-controlled Internet offers seems to be important to capitalise on the potential of the Internet.